Background : Triple synchronous primary malignancy is not common. With the advancement of radiological and endoscopic tools makes achieving precision in diagnosis less challenging. 65-year old man presented to our outpatient department in May 2022 because of mild jaundice and right upper quadrant intermittent pain. He had chronic hepatitis C and alcohol related liver cirrhosis. Contrast enhanced CT scan revealed Hepatocellular carcinoma in segment 7 and proximal bile duct obstruction. He further went for ERCP and stenting with brush biopsy revealed atypical cells and also a lesion was seen and biopsy revealed early gastric cancer.

Methods : The patient underwent Right hepatectomy, extrahepatic bile duct resection, hepaticojejunostomy and regional lymphadenectomy. He had long perioperative period in hospital due to postoperative liver dysfunction with peak ascites drain output of 2000ml per day. He was discharged on 30th postoperative day and was sent to our endoscopic department for ESD procedure. Surgical pathology revealed hepatocellular carcinoma with pT2, Cholangiocarcinoma of proximal bile duct and early gastric adenocarcinoma with pT1a. Post endoscopic procedure was uneventful and he was discharged on 2nd post-procedural day. After multiple curative procedures, Oncology department consultation decision was made and he was treated adjuvant chemotherapy based on NCCN guideline.

Results : The patient is on his 3 monthly follow up examination on both surgical and oncological department. No recurrence or metastasis is noted on either locoregional or distant organs.

Conclusions : Here we report an uncommon case of triple synchronous malignancy of HCC, Proximal bile duct and early gastric cancer treated with curative surgery and adjuvant therapy.